The overall objective is to compare the effect of Vancomycin and Tobramycin powder combined (treatment) to Vancomycin powder (control) in the reduction of post-fixation infections of tibial plateau and tibial pilon fractures at high risk of infection (collectively considered the "study injuries").

Specific Aim 1: Compare the proportion of deep surgical site infections (SSI) of the study injury within 182 days of definitive fracture fixation surgery in patients allocated to receive a combination of local Vancomycin and Tobramycin powders compared to patients allocated to local Vancomycin powder.

Sensitivity Analyses: A series of sensitivity analyses will be conducted to look at alternative measures of deep SSI under Specific Aim 1. These sensitivity analyses will consider the following alternative end points of deep SSI: infection by only gram-negative bacteria, infection by any gram-positive bacteria (with or without other organisms of any type), polymicrobial pathogenic infections, culture negative infections, and cellulitis/skin infections.

Specific Aim 2: To compare the safety of treatment with a combination of local Vancomycin and Tobramycin versus Vancomycin powder alone as measured by the proportion of antibiotic resistance in each arm.

Inclusion Criteria:

• Tibial plateau or tibial pilon fractures that is treated operatively with plate and screw fixation AND at least one of the following characteristics indicative of higher risk of infection:

  1. Initially treated with an external fixation and treated definitively more than 3 days later after swelling has resolved.
  2. Any open type I, II, or IIIA fracture, regardless of timing of definitive treatment.
  3. Tibia fracture is associated with ipsilateral leg compartment syndrome and fasciotomy wounds.

• Patients ages 18 through 80 years.

Exclusion Criteria:

• Study injury is already infected at time of study enrollment.
• Definitive fixation of the study injury prior to enrollment in the study.
• The patient never receives study fixation.
• Massive myonecrosis from ipsilateral leg compartment syndrome.
• Currently pregnant.
• Severe problems with maintaining follow-up (e.g. patients who are homeless at the time of injury, those who are intellectually challenged without adequate family support, or are unwilling to provide phone and address contact information).
• Patients with allergies, drug administration reactions, or other sensitivities to Vancomycin (such as a history of Redman's Syndrome).
• Patients with allergies, drug administration reactions, or other sensitivities to Tobramycin or other aminoglycosides.